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Low-Income Telephone and Electric Discount Programs Enrollment Form (LITEUP) For Questions, Call LITE-UP Texas toll-free at 1-866-454-8387
Full Name: _______________________________________ Address 1: _______________________________________ Address 2: _______________________________________ City, State Zip: ____________________________________
ABOUT THE PROGRAMS
The Telephone Discount Program • Available to qualified low-income customers. • Also available if a resident member of your household is a recipient of a qualified program. • The Program can provide a discount up to $13.50 off your telephone bill. • Your discount will appear on the next telephone bill after your completed application and documentation have been approved. The Electric Discount Program • Available to qualified low-income customers. • The program can provide a discount on your electric bill if you live in an area where you have a choice of electricity provider. • The electric discount program is a five month program. • The discount will be on the May thru September bills ONLY, after your completed application and documentation have been approved. Program Rules • You must notify LITE-UP Texas in writing if you no longer qualify for the discount. Send notice to: LITE-UP Texas, 1779 Wells Branch Parkway, Suite 110B #357, Austin, TX 78728-7022. • You must notify LITE-UP Texas to report any change in address or telephone number. • You must provide a copy of your latest Telephone bill AND Electric bill with this application. o Please submit photocopies of all documents, original documents will not be returned. • You must complete the applicable sections below as follows: o Section 1 – This section must be completed by the person in whose name the service is billed. The person in whose name the electric service is billed must reside at the service address for this electric service. o Section 2 – If applying for the LITE-UP Program based on income, then your total household gross income must be at or below the applicable level indicated in the application: You must provide proof of income. This section must be completed by the person in whose name the telephone and/or electric service is billed. o Section 3 - If the person receiving the Eligible Benefits is a different resident household member than the person whose name is on the telephone bill, then the resident household member receiving the benefits must complete and sign Section 3. If the benefit recipient is a minor child, then one of the minor child's parents must complete and sign this section for the minor child. The person receiving the eligible benefit(s) must provide proof that he/she participates in one of the eligible programs. Note: This is only applicable to Telephone Discounts. o Section 4 – The person in whose name the telephone or electric service is billed must complete and sign this section.
________ Social Security Number: ______ .913 7 $49.538 2 $21. Copy of an unemployment form with eligibility dates.515 $46. Documentation of social security income.____ .263 Income Source Wages from Employment as shown on pay stub or W-2 Form Social Security Retirement Income Alimony or Child Support Unemployment or Worker's Compensation All Other Earnings Dollar Amount PROVIDE PROOF OF HOUSEHOLD INCOME WITH THIS APPLICATION (provide all documents that apply) • Copy of most recent pay stub(s) from all employers • • • • • covering the last two months (for all members of the household).075 $27.888 4 $33.588 8 $55. For the Telephone discount ONLY.________ YOU MUST INCLUDE A COPY OF YOUR LATEST TELEPHONE AND ELECTRIC BILLS SECTION 2 – Income Enrollment If applying for the Discount Programs based on income.295 $36.563 5 $38. TX Zip Code: ____________________ Telephone Number: ( ______ ) ______ . your total household gross income must be less than the requirements listed below.213 3 $27.Applicant Information The person whose name is on the Telephone and Electric bills MUST fill out this section.685 $32. . A signed letter from each employer indicating the level of your wage.905 $41. Your most recently filed tax return (must be signed) or W2.238 6 $44. Copies of the two most recent unemployment checks Copy of the most recent bank statement showing direct deposit of income.245 $13.855 $18.465 $22. HOUSEHOLD SIZE – Total (Include all adults and children residing at this service address) Number of people living in your household: _____ HOUSEHOLD INCOME WORKSHEET Your total household gross annual income from all sources cannot exceed these guidelines: Number of persons in Household Total Household annual income Telephone Total Household annual income Electric 1 $16. Name of Telephone Customer: _________________________________________________________ As it appears on your utility bill (please print) Name of Electric Customer: If different from above _________________________________________________________ (please print) Address: _________________________________________________________________________________ City: ___________________________________________. the qualifying resident member must live at the service address. The person in whose name the utility bills appear must live at the service address.Public Utility Commission of Texas SECTION 1.
________ Social Security Number: ______ .____ .Declaration (please read carefully and sign) The person in whose name the utility service is billed must complete and sign this section.LIHEAP Federal Public Housing Assistance Eligible Resident of Tribal Lands (please indicate which tribe): __________________________________________ Tribe Name Enrollment in any of the programs listed below will qualify you for the Electric discount. I state that the information I have provided in this application is true and correct. I understand that the information provided is subject to audit and investigation by the Public Utility Commission of Texas. By signing this form. then the resident household member receiving the benefits must complete and sign Section 3.________ Date: ________________________ X _____________________________________________________ Eligible Benefit Recipient Signature X _____________________________________________________ Parent's Signature if Eligible Recipient is a Minor Child Date: ________________________ YOU MUST PROVIDE PROOF OF PROGRAM PARTICIPATION WITH THIS APPLICATION SECTION 4 . X _____________________________________________________ Applicant’s Signature Date: ________________________ Mail Completed Application and Required Documentation to: LITE-UP Texas 1779 Well Branch Parkway Suite 110B #357 Austin. If the benefit recipient is a minor child. The person receiving the eligible benefit(s) must provide proof that he/she participates in one of the eligible programs. TX 78728-7022 . Name of Benefit Recipient: _______________________________________________________________________ Telephone Number: ( ______ ) ______ . then one of the minor child's parents must complete and sign this section for the minor child.Public Utility Commission of Texas SECTION 3— Program Benefit Enrollment Enrollment in any of the programs listed below will qualify you for the telephone discount. Food Stamps Medicaid Supplemental Security Income-SSI Health Benefit Coverage under Child Health Plan (CHIP) Low-Income Energy Assistance Program . Food Stamps Medicaid Benefit Recipient – Telephone Discount Only If the person receiving the Eligible Benefits listed above is a different resident household member than the person whose name is on the telephone bill.
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